The stakes for health care

The fate of America's inadequate, unaffordable and unequal health care system is on the ballot. Harris gives us a chance to make it better. A Trump victory guarantees something worse.

When asked if health care is on the ballot this November, most voters immediately respond yes and have strong opinions about the issue. Either they are for reproductive health rights and elective abortions and are voting for Kamala Harris, or they are against both and are voting for Donald Trump.

Most people don’t know or are dimly aware that Harris has also proposed the most significant Medicare expansion since adding a prescription drug benefit in 2003. Her plan would be wildly popular if more people knew about it. Nor do they realize that a second Trump presidency, especially if Republicans also win control of Congress, will result in millions of people losing their health insurance coverage or seeing their benefits sharply reduced.

In early October, Vice President Harris, surrounded by the hosts of ABC’s The View, announced plans to add a home-care benefit to Medicare. It would provide financing for in-home aides to help with the daily living tasks of infirm elderly and disabled family members struggling to stay out of nursing homes. Most of that care is provided by unpaid relatives unless the beneficiary qualifies for Medicaid, which requires exhausting one’s assets first.

Citing her own struggles with helping her mother while she was dying of cancer, Harris pledged to help the sandwich generation that finds itself taking care of both young children and an elderly parent. “Giving that support to your family members means losing as much as you can to be able to go on Medicaid or having to leave your job,” Harris told cheering supporters at a recent rally. “That means cutting off a very important part of your income just to give the people in your life the dignity and support they deserve.”

There’s hope for long-term care at home

Recent polling shows 75 percent of U.S. adults support a program to help pay for long-term care, which European countries and Japan provide through a mandatory requirement to purchase long-term care insurance, taxpayer-financed programs, or a combination of both. Like health insurance, the U.S. is the only advanced industrial nation that doesn’t have a universal long-term care program. Yet, among Americans, “two-thirds support a government-administered long-term care insurance program, government funding for low-income people to receive long-term care in their homes, or Social Security earnings credit for providing care to a loved one,” the 2022 Associated Press-NORC Center for Public Affairs Research poll on long-term care found.

The need for such a program is enormous. Nearly 50 million Americans, or 20 percent of all households—up from 15 percent a decade ago—provide unpaid care for loved ones living at home when they need help with the basic tasks of daily living like dressing, bathing, toileting, and feeding. That number will grow substantially over the next two decades as the Baby Boomer generation moves through its final years. The potential beneficiary population includes not just the elderly incapacitated by dementia and other diseases but also younger family members with severe mental and physical disabilities.

The strain of working what is essentially a second job—taking care of someone at home, a labor that falls to a woman 65 percent of the time—can take a huge toll on the caregiver’s health. They lose touch with friends. They’re emotionally exhausted. They too often wind up ignoring their health. About a third of caregivers skip routine physical or dental care because they are consumed with caregiving duties, according to the 2018 poll by AP-NORC. Nearly 40 percent have their own physical or mental problems.

A universal at-home care program will be costly. Providing in-home aides to help the helpers will cost Medicare an estimated $40 billion a year, according to a recent Brookings commentary. Issued just three weeks before Harris announced her plan, its authors included Jonathan Gruber, a key architect of the Affordable Care Act, and Wendell Primus, who served for many years as chief health care policy staffer to Representative Nancy Pelosi, the former Speaker of the House.

Their plan called for a means-tested program free to low-income people, including escalating co-pays for those with higher incomes. In addition to Medicaid, the home health aide industry relies on wealthier families paying out-of-pocket when employing in-home health aides for their loved ones.

While the benefit could be paid for by general taxation, an Urban Institute report issued six years ago called for funding a long-term care program with a surcharge on the Medicare payroll tax, currently set at 2.9 percent of income split evenly between workers and employers. The surcharge wouldn’t kick in until workers turned 40.

On the campaign trail, Harris said she would pay for the program through the savings from negotiating lower drug prices, one of the major health care accomplishments of the Biden-Harris administration’s first four years in office. However, the Congressional Budget Office estimates drug price negotiations over the next ten years will only save about $100 billion, which is only a quarter of what the Brookings authors estimate a home-care benefit will cost over a decade.

Yet the CBO’s bean-counting approach fails to consider the financial gains from a home-care benefit. Studies of pilot programs from the Centers for Medicare and Medicaid Services that provide caregivers with in-home aid show they reduce emergency room visits, hospitalizations, and admissions to nursing homes. Employers benefit from more productive workers who are under less stress and no longer need time off to care for loved ones. State budgets benefit from Medicare taking over Medicaid’s home care program, which frees up resources for other state programs or tax relief.

Recognizing any home health program’s potential popularity, Republicans updated their 2024 party platform to include a short section promising to “protect care at home for the elderly.” However, their proposed solutions, which are to “shift resources back to at-home senior care, overturn disincentives that lead to care worker shortages, and support unpaid family caregivers through tax credits and reduced red tape,” ignore basic facts.

There is no Medicare at-home benefit that had resources taken away from it. Care worker shortages are due to ridiculously low pay, which Republicans have enabled by refusing to raise the federal minimum wage or Medicaid rates in the states they control. And tax credits are mostly useless to the less well-off who pay little or no federal income tax. They will go mainly to the well-off since the modest taxes paid by people in the lower half of the income distribution are far less than the cost of an in-home health care aide.

Obamacare’s on the ballot, too

Meanwhile, the Republican platform and Trump have been purposely silent about the biggest health care issue that will confront millions of Americans next year: the expiration of the expanded subsidies for individual and family health insurance plans sold on the Obamacare exchanges. Over the past three years, they helped lower the uninsured rate to about 8 percent—the lowest in U.S. history.

Should Trump return to office, those subsidies will be on the chopping block next year to help pay for the renewal of his 2017 tax cut, which went mainly to the wealthy and large corporations. Experts say that without those additional Obamacare subsidies, millions will forgo purchasing insurance because it is no longer affordable—something that happened during Trump’s first term when the uninsured rate went up.

Trump also never mentions plans by the architects of Project 2025, who are likely to fill key positions at his health care agencies, to return to policies that undermined the quality of health insurance. They include the sale of short-term insurance plans that leave purchasers with huge bills when they get sick and don’t meet current regulatory standards like free preventive services and guaranteed issue (no discrimination for pre-existing medical conditions); a sustained push for turning Medicaid into block grants, which will result in colossal service cuts in many states; and turning Medicare entirely over to the private insurance industry, which already enrolls over half of beneficiaries at a cost that is higher for taxpayers than the cost of those who remain in the traditional program.

When Harris says, “We’re not going back,” she’s not kidding. Her healthcare plans preserve the gains rendered by Obamacare and build on them through her new home care benefit. Trump—and those who hope to ride into office on his coattails—plans to go back by reversing the gains made under the Affordable Care Act and returning to the era when one in six Americans went without coverage and tens of millions were left with skimpy coverage that left them in medical debt.

This article first appeared yesterday on the Washington Monthly website.